Methods and systems for preparing bone for a surgical procedure

ABSTRACT

Systems and methods for preparing a bone for a surgical procedure are provided. In general, the described techniques use a surgical guide device including a cannula having first and second parallel elongate channels adjacent to one another, and first and second elongate sleeves configured to be removably and replaceably received in the first and second channels, respectively. The first sleeve has a plurality of openings formed therein, each being in communication with a respective wire-receiving lumen extending through the first sleeve. Each of the openings defines a different offset distance between the wire-receiving lumen in communication with that opening and a wire-receiving lumen extending through the second sleeve. The surgical device can be manipulated so as to define positions of first and second openings in a bone, such as a glenoid or other bone, to receive bone screws or other elements for attaching a bone graft to the bone.

CROSS REFERENCE TO RELATED APPLICATIONS

The present application is a continuation of U.S. patent applicationSer. No. 14/983,383 entitled “Methods And Systems For A Bone PreparationFor A Surgical Procedure” filed Dec. 29, 2015, which is herebyincorporated by reference in its entirety.

FIELD

The present disclosure relates to methods and systems for a bonepreparation for a surgical procedure.

BACKGROUND

The shoulder joint has the largest range of motion of any joint in thehuman body. It is a ball-and-socket joint having three bones: a shoulderblade (scapula), a collarbone (clavicle), and an upper arm bone(humerus). A rounded head of the upper arm bone (humeral head) fits intoa shallow socket in the shoulder blade called a glenoid. The humeralhead is usually much larger than the glenoid, and together they havelittle inherent stability. The shoulder joint is thus prone toinstability and dislocation. A soft fibrous tissue rim called a labrumsurrounds the glenoid to form a cup for the humeral head to move withinthe glenoid. The labrum thus helps maintain stability of the shoulder,while allowing for a very wide range of motion. When the labrum of theshoulder joint is damaged, the stability of the shoulder joint iscompromised, leading to subluxation and dislocation of the joint.Recurrent dislocations may cause damage to the bones of the joint - thehumeral head and the glenoid. In particular, damage to theanterior-inferior part of the glenoid will cause a decrease in the areaof contact with the humeral head.

Surgical procedures intended to address the shoulder instability aretypically divided into soft tissue and bony procedures. Surgicalreconstruction targeting the shoulder joint's soft tissues (whichtypically involves labral repairs) can be adequate to address certainshoulder instability problems. However, in cases where significant bonedeficiency is present (e.g., when greater than 20% of the glenoid'ssurface area is missing), addressing only the soft tissue issues istypically not sufficient. Bone deficiency can result from trauma,overuse, congenital deformity, or recurrent dislocation.

Reestablishment of shoulder stability requires recognition and treatmentof bone defects. When bone deficiencies or lesions reach certaindimensions, reconstruction of these deficits is typically performedusing a bone graft. Although existing techniques have been used withsome success, the bone graft may not be properly aligned with theglenoid or other bone structure being reconstructed. In particular, whenthe bone to be reconstructed is being prepared for receiving the graft,it may be challenging to identify proper locations for attachmentelements (e.g., screws) that are to be inserted into the bone when thegraft is attached thereto.

Accordingly, there is a need for improved techniques and devices forpreparing a bone for a surgical procedure, such as a procedure involvinguse of a bone graft.

SUMMARY

In some aspects, a surgical guide device is provided that includes acannula comprising first and second parallel elongate channelspositioned adjacent to one another, a first elongate sleeve configuredto be removably and replaceably received in the first channel, and asecond elongate sleeve configured to be removably and replaceablyreceived in the second channel. The first sleeve has a proximal housingconfigured to protrude from a proximal end of the cannula, and theproximal housing of the first sleeve has a plurality of openings formedtherein, each opening being in communication with a respectivewire-receiving lumen that extends through the first elongate sleeve to adistal end thereof. The second sleeve has a proximal end configured toprotrude from the proximal end of the cannula when the second sleeve ispositioned therein, the second sleeve having a wire-receiving lumenextending therethrough.

The surgical guide device can vary in any number of ways. For example,the surgical guide device can further include a coupling elementconfigured to couple the first sleeve to the second sleeve so as toprevent rotation of the first and second sleeves with respect to oneanother.

In some embodiments the cannula extends from a proximal handle. Theproximal handle can be non-removably coupled to the cannula. The firstand second parallel elongate channels can be discrete and separatechannels.

The first and second elongate sleeves can have a number of differentconfigurations. For example, in some embodiments, the plurality ofopenings formed in the first sleeve can include three openings. Each ofthe three openings can define a different offset distance between thewire-receiving lumen in communication with the opening and thewire-receiving lumen extending through the second elongate sleeve.

The first and second elongate sleeves can be removably and replaceablydisposed in the first and second elongate channels via a clearance fit.The second elongate sleeve can extend more proximally beyond a proximalend of the cannula than the first elongate sleeve. For another example,the housing of the first sleeve can be an elongate tubular housinghaving a diameter that is larger than a diameter of an opening leadingto the first channel of the cannula. In at least some embodiments, theproximal end of the first sleeve has a washer-like shape. In at leastsome embodiments, a distal end of the second sleeve has a threadedportion.

The distal end of the first sleeve can be configured to extend beyond adistal end of the cannula when the first sleeve is positioned therein. Adistal end of the second sleeve can be configured to extend beyond adistal end of the cannula when the second sleeve is positioned therein.

In some aspects, a method for preparing a bone for a surgical procedureis provided that includes positioning a cannula having first and secondparallel elongate channels adjacent to one another along an end surfaceof the bone such that the first and second parallel elongate channelsare disposed in a first plane, positioning a first wire in the firstchannel such that the first wire extends along a plane defined by theend surface of the bone, and positioning a second wire in the secondchannel and inserting a distal end of the second wire into a portion ofthe bone spaced away from the end surface to define a first opening inthe bone. The method further includes at least partially retracting thefirst wire from the first channel and rotating the cannula about thesecond wire while the second wire remains in place, and, after thecannula is rotated, inserting the first wire through the bone to definea second opening in the bone.

The method can vary in any number of ways. For example, the first wirecan be inserted into the cannula through a first elongate sleevedisposed in the cannula, and the second wire can be inserted into thecannula through a second elongate sleeve disposed in the cannula. Foranother example, the method can further include inserting the secondwire into the bone to an increased depth

In some embodiments, the cannula can be rotated about the second wiresuch that the first and second parallel elongate channels are disposedin a second plane that is substantially perpendicular to the firstplane.

In some embodiments, the method further includes attaching a bone graftto the bone using first and second screws, the first screw extendingthrough the bone graft and into the first opening in the bone, and thesecond screw extending through the bone graft and into the secondopening in the bone.

The bone can be a glenoid or other bone structure.

BRIEF DESCRIPTION OF THE DRAWINGS

The embodiments described above will be more fully understood from thefollowing detailed description taken in conjunction with theaccompanying drawings. The drawings are not intended to be drawn toscale. For purposes of clarity, not every component may be labeled inevery drawing. In the drawings:

FIG. 1A is a perspective view of a portion of a shoulder joint, showinga glenoid and an intact coracoid;

FIG. 1B is a perspective view of the portion of the shoulder joint ofFIG. 1A, showing a bone graft created by cutting off a portion of thecoracoid;

FIG. 1C is a perspective view of the portion of the shoulder joint ofFIG. 1B, illustrating generally a Latarjet procedure used to attach thebone graft to the glenoid;

FIG. 2 is a perspective view of a glenoid with a bone deficit;

FIG. 3 is a perspective view of the glenoid of FIG. 2, showing a bonegraft attached to the glenoid to compensate for the bone deficit;

FIG. 4A is a perspective view of one embodiment of a cannula havingfirst and second elongate channels, and a handle coupled to the cannula;

FIG. 4B is another perspective view of the cannula of FIG. 4A;

FIG. 5 is a perspective view of the cannula of FIG. 4A and first andsecond elongate sleeves configured to be received in the first andsecond elongate channels of the cannula;

FIG. 6 is a perspective view of the cannula of FIG. 5, showing the firstand second elongate sleeves received in the first and second elongatechannels;

FIG. 7A is a perspective view of one embodiment of a first elongatesleeve;

FIG. 7B is another, enlarged perspective view of the first elongatesleeve of FIG. 7A, illustrating openings in a proximal end of thesleeve;

FIG. 7C is another, enlarged perspective view of the first elongatesleeve of FIG. 7A, illustrating wire-receiving lumens extending throughthe sleeve;

FIG. 8A is a perspective view of one embodiment of a second elongatesleeve;

FIG. 8B is an enlarged perspective view of a distal end of the secondelongate sleeve of FIG. 8A;

FIG. 9 is a perspective view of one embodiment of a surgical guidedevice, illustrating the surgical guide device positioned adjacent to aglenoid during a bone reconstruction procedure;

FIGS. 10A-10F illustrate one embodiment of a method for preparing aglenoid for a surgical procedure, using one embodiment of a surgicalguide device;

FIG. 11 illustrates the glenoid prepared for a surgical procedure usingthe method of FIGS. 10A-10F; and

FIG. 12 illustrates openings for bone screws defined in a glenoidprepared for a surgical procedure using a method in accordance with thedescribed embodiments.

DETAILED DESCRIPTION

Certain exemplary embodiments will now be described to provide anoverall understanding of the principles of the systems and methodsdisclosed herein. One or more examples of these embodiments areillustrated in the accompanying drawings. Those skilled in the art willunderstand that the systems and methods specifically described hereinand illustrated in the accompanying drawings are non-limiting exemplaryembodiments and that the scope of the embodiments is defined solely bythe claims. Further, the features illustrated or described in connectionwith one exemplary embodiment may be combined with the features of otherembodiments. Such modifications and variations are intended to beincluded within the scope of the described embodiments.

The embodiments described herein generally relate to systems and methodsfor preparing a bone for a surgical procedure, and for properly mating abone graft to the base bone in a manner that enables the graft to beflush when mounted to the base bone. The bone can be, for example, aglenoid or other bone structure. The bone is prepared so that it canreceive a graft that compensates for certain deficiency in the bone. Forexample, in a glenoid reconstruction procedure, the glenoid with somedegree of bone deficit and associated loss of shoulder stability canhave a bone graft attached thereto to treat the shoulder instability. Toprepare the bone, positions of openings in the bone, which will receivetherein bone screws or other attachment elements that attach the graftto be bone, are defined. In the described embodiments, the openings aredefined in a straightforward and simplified manner, such that, unlike inconventional approaches, the outcome of the surgical procedure becomesless dependent on a surgeon's experience. A likelihood of patient'sinconvenience and damage to the surgical site is thus greatly reduced.

To define the openings in the bone, the described techniques use asurgical guide device including a cannula having a handle coupledthereto that allows manipulating the cannula. The cannula has first andsecond parallel elongate channels extending therethrough adjacent to oneanother. The surgical guide device also includes first and secondelongate sleeves configured to be removably and replaceably received inthe first and second elongate channels, respectively. The first andsecond elongate sleeves are typically fully cannulated such that theycan receive wires (e.g., K-wires) in their wire-receiving lumensextending therethrough.

The first elongate sleeve has, at a proximal end thereof, a plurality ofopenings formed therein, each of which leads to a respectivewire-receiving lumen or channel that extends through the first elongatesleeve to a distal end thereof. Three or other number of openings can beformed at the proximal end of the first elongate sleeve. Each of theopenings defines a different offset distance between the wire-receivinglumen in communication with that opening and a wire-receiving lumenextending through the second elongate sleeve. The offset distance, inturn, defines an offset distance of openings to be formed in the bonefrom a certain portion of the bone, such as an end surface of the bone.For example, when the bone is a glenoid, the openings are defined in aglenoid rim at a predefined offset distance from the edge of the glenoidrim.

During preparation of a bone for a surgical procedure, the cannula isfirst positioned along an end surface of the bone such that the firstand second elongate channels in the cannula are disposed in a firstplane. A desired offset distance is then selected, which is done bypositioning a first wire in one of the plurality of openings in thefirst sleeve, the opening leading to a corresponding wire-receivinglumen in the first sleeve. When the first wire is inserted into thecannula in this manner, the opening in the first sleeve of the cannulais aligned with the end surface of the bone. A second wire is theninserted into the second sleeve and advanced into the bone to define afirst opening in the bone. The first wire is then at least partiallyretracted from the first channel (e.g., it can be removed from the firstchannel) to allow the cannula to be manipulated. In the illustratedembodiments, the cannula is rotated about the second wire while thesecond wire remains in place (inserted in the bone). As a result of therotation of the cannula, the position of the first channel with respectto the bone is changed such that both the first and second channels canbe disposed in a second plane that is substantially perpendicular to thefirst plane. After that, the first wire is again inserted into the firstchannel to define a second opening in the bone.

The techniques described herein can be used to prepare a bone for avariety of different surgeries. Among various bone reconstructionprocedures to correct a bone defect or fracture, the Latarjet procedureis a commonly used procedure involving removal and transfer of a portionof a coracoid bone, or coracoid, to the anterior glenoid. The Latarjetprocedure is used to repair an anterior shoulder dislocation or erosionof the shoulder joint, and prevent further loss of bone. The placementof the coracoid acts as a bone bloc or graft, which, combined with thetransferred muscles acting as a strut, increases stability of theshoulder joint and thus prevents its further dislocation. FIGS. 1A, 1B,and 1C illustrate generally a Latarjet procedure for reconstruction of abone deficiency in a glenoid 100. It should be appreciated that only aportion of a shoulder is shown in FIGS. 1A-1C.

The glenoid 100 can have a bone defect in an area 101 thereof, which isidentified in FIGS. 1A and 1B. The coracoacromial ligament and thepectoralis minor attachment are divided, whereas coracobrachialis andthe short head of the biceps origins remain intact. A coracoid 102 isosteotomized at a level of its “knee” 104 so as to form a bone graft106, as schematically shown in FIGS. 1A and 1B. As also shown, aconjoined tendon 108 remains attached to the coracoid bone graft 106.The bone graft 106 can be prepared for bone reconstruction usingsuitable techniques as known in the art. For example, it can be shapedand contoured to fill the bone defect in the area 101 of the glenoid100.

To increase the bone area of the glenoid 100, the appropriately preparedbone graft 106 is then attached to the glenoid 100, as shown in FIG. 1Cwhere the glenoid 100 is shown at least partially transparent forillustration purposes only. As FIG. 1C illustrates, the bone graft 106can be attached to the glenoid 100 using screws 110, 112 that areinserted at the anterior rim of the glenoid 100. The coracoid bone graft106 thus fills the bone deficiency of the glenoid 100, and the conjoinedtendon 108 provides a sling effect, stabilizing the shoulder.

FIGS. 2 and 3 additionally illustrate an example of a glenoid 120 havingan area 121 with a bone defect which can be compensated for by attachinga bone graft 126 to the rim of the glenoid 120 using first and secondscrews 130, 132.

During a Latarjet surgery, the ability to reliably position the coracoidbone graft adjacent to the glenoid such that the graft is flush with theglenoid surface depends on the skill and experience of a surgeonperforming the procedure. For example, instead of being positioned flushwith the glenoid's surface, the bone graft can be placed medially orlaterally removed from the glenoid rim. However, if the bone graft isdisposed too medially from the glenoid rim, there may be a highlikelihood that the surgical procedure will not adequately correct theinstability of the shoulder. On the other hand, if the bone graft isdisposed too laterally of the glenoid rim, the humeral head will touchthe bone graft which can lead to damage to the cartilage. As anotherhighly undesirable consequence, if the surface of the bone graft is notparallel to the glenoid surface, a screw may be inserted into the jointrather than into the glenoid, which can cause severe bone damage.

Accordingly, the described devices and techniques provide a way toposition a bone graft adjacent to a bone structure with a bonedeficiency in a more precise and simplified manner. More specifically,the described devices and techniques provide a way to prepare a bone fora surgical procedure involving attachment of a bone graft to the bone.Thus, techniques are provided for preparing a glenoid to receive acoracoid bone graft as part of a glenoid bone reconstruction procedure.Referring back to FIGS. 2 and 3, these techniques allow alignment of thebone graft 126 with the surface of the glenoid 120 to be accomplished ina reliable and straightforward manner. The outcome of the procedure isthus less dependent on the level of skill and experience of a surgeon,which can improve the success and efficiency of the surgery. It shouldbe appreciated that, while the techniques presented herein are describedin connection with a glenoid bone reconstruction procedure, other bonestructures can be prepared for bone reconstruction procedures using thedevices and methods in accordance with such techniques.

As mentioned above, a bone graft can be attached to a bone to compensatefor a bone deficit using first and second screws, such as, for example,screws 110, 112 in FIG. 1C or screws 130, 132 in FIG. 3. To properlyalign the bone graft with the bone such that their surfaces are flushwith one another, the bone graft and the screws that secure it should bepositioned at an appropriate offset with respect to the bone. Thus,during a glenoid reconstruction, the coracoid bone graft must be placedat an appropriate offset from the glenoid rim. It is therefore necessaryto determine proper locations for holes or openings in the glenoid thatreceive the bone screws used to attached the bone graft to the glenoid.

FIGS. 4A, 4B, 5, 6, 7A, 7BV, 7C, 8A, and 8B illustrate surgical guideinstruments that can be used to determine and effect the properpositioning of first and second openings in the glenoid in accordancewith the present disclosure. The locations of the openings are definedusing a surgical guide device configured to receive therethroughelongate wires, such as K-wires or other temporary fixation elements, asdiscussed below. The surgical guide instruments described herein allowpreparation of a bone for a surgical procedure such that a graft canlater be attached to the prepared bone while the graft is positionedflush with the bone. It should be noted, that, as used herein, the term“flush” means that the graft's surface will be substantially alignedwith the bone's surface. The anatomy of the bone and/or configuration ofthe graft can be such that their surfaces are curved and not flatthroughout. Also, a certain offset between the surfaces of the bone andthe graft is permissible, as long as the alignment is sufficient toprovide stability to the site being reconstructed and without damaginganatomical structures involved.

A surgical guide device can include a cannula, one embodiment of whichis shown in FIGS. 4A and 4B. As illustrated, a cannula 200 havingproximal and distal ends 200 p, 200 d is in the form of an elongatetubular body with its proximal end 200 p extending from a proximalhandle 204. The cannula 200 has first and second parallel elongatechannels 206, 208 extending therethrough, and FIGS. 4A and 4B illustrateopenings 206 o, 208 o leading to the first and second channels 206, 208,respectively. The elongate channels 206, 208 are positioned adjacent toone another and their longitudinal axes A1, A2 are parallel to oneanother. The elongate channels 206, 208 can be discrete and separatechannels. In some embodiments, the elongate channels 206, 208 can havethe same diameter, which can be, for example, about 0.25 inches.However, a person skilled in the art will appreciate that the elongatechannels can have a diameter greater or less than 0.25 inches, and thatchannels 206, 208 need not have the same diameter.

It should be appreciated that, as used herein, and unless otherwisespecified, the terms “first” and “second” are used to differentiatebetween the elongate channels or other components so defined, and not toindicate any particular order of the components.

In some implementations, the cannula 200 can be at least partiallytransparent. Furthermore, additionally or alternatively, outer walls ofthe first and second elongate channels 206, 208 can have one or moreopenings or windows formed to enable observation of the interior of thechannels, and a positon of an instrument introduced into the channel(s).For example, a window can be formed through the wall of each of thechannels in proximity to a distal end of the channel. The window can becovered by a transparent or partially transparent material, or it maynot be covered and be in the form of an opening.

The proximal handle 204 can have a variety of configurations. In theembodiments described herein, the handle 204 can be a pistol grip-typeelement that is attached to the cannula 200 at an angle a relative tothe longitudinal axes A1, A2 of the channels, as indicated in FIG. 4A.In some embodiments, the angle a can be from about 40 degrees to about65 degrees, which can allow maneuvering the cannula by holding thehandle 204 without obstructing the field of vision. However, the handle204 can be disposed at other angles with respect to the cannula 200. Inthe described embodiments, the handle 204 can be non-movably coupled tothe cannula 200. In use, the handle 204 can be manipulated so as tochange a position of the cannula 200. A person skilled in the art willappreciate that the handle 204 can be integrally formed with the cannula200, or it can be removably attached to the cannula.

The proximal handle 204 can be configured to provide an adequate grip,and thus it can have surface features that facilitate grasping andmanipulating the device. In the example illustrated, the handle 204 isgenerally cylindrical, although it has features such that its diametervaries along its length. For example, as shown in FIG. 4A, the handle204 can have a longer proximal portion 204 p and a shorter distalportion 204 d coupled to the cannula 200. As shown, the proximal portion204 p has an enlarged mid-portion and has ridges 205 that facilitategrip, which are also shown in FIGS. 5 and 6. The ridges 205 can formvarious patterns on the handle's surface. The distal portion 204 d,which also has ridges similar to the ridges 205, has a bulge-likeportion 207 a adjacent to the proximal portion 204 p, and a distallytapered portion 207 b having a smaller diameter than the portion 207 a.As a person skilled in the art will appreciate, the handle 204 can haveany suitable surface features, including the same or different features,which can form regular or irregular patterns on the handle's surface.

In the illustrated embodiments, the first and second elongate channels206, 208 of the cannula 200 are configured to receive therein respectivefirst and second elongate sleeves that can be fully cannulated and, inturn, have one or more wire-receiving lumens extending therethrough.Thus, as shown in FIGS. 5 and 6, the first and second elongate channels206, 208 of the cannula 200 can accommodate respective first and secondelongate sleeves 216, 218 removably and replaceably received therein.FIG. 5 illustrates the first and second elongate sleeves 216, 218outside of the first and second elongate channels 206, 208. As shown,the first and second first and second sleeves 216, 218 have respectiveproximal ends 216 p, 218 p and respective distal ends 216 d, 218 d thatare passed through openings of the elongate channels 206, 208 before theproximal ends 216 p, 218 p when the sleeves 216, 218 are inserted intothe channels 206, 208.

FIG. 6, showing the cannula 200 transparent for illustrative purposesonly, illustrates the first and second sleeves 216, 218 received withinthe first and second elongate channels 206, 208, respectively. The firstand second elongate sleeves 216, 218 can be removably and replaceablydisposed in the first and second elongate channels 206, 208 via aclearance fit. As shown, the proximal end 216 p of the first sleeve 216is configured to protrude from the proximal end 200 p of the cannula 200when the first sleeve 216 is positioned therein. Similarly, the proximalend 218 p of the second sleeve 218 is configured to protrude from theproximal end 200 p of the cannula 200 when the second sleeve 218 ispositioned therein. Furthermore, in some embodiments, the distal ends216 d, 218 d of the first and second sleeves 216, 218 can extend beyondthe distal end 200 d of the cannula 200 when the first and secondsleeves 216, 218 are positioned within the cannula 200.

The first and second elongate sleeves 216, 218 can have variousdifferent configurations. As shown in FIGS. 5 and 6, the second sleeve218 can have a greater length than the first sleeve 216 such that thesecond elongate sleeve 218 can extend more proximally beyond theproximal end 200 p of the cannula 200 than the first elongate sleeve216. Also, in the illustrated embodiments, the first and second sleeves216, 218 have different configurations, as also shown in FIGS. 7A-7C andFIGS. 8A and 8B. For example, the proximal end 216 p of the firstelongate sleeve 216 can have a washer-like shape, whereas the proximalend 218 p of the second elongate sleeve 218 can be more elongate andhaving a diameter than is less than a diameter of the washer-like theproximal end 216 p of the first elongate sleeve 216. Furthermore, whilethe second sleeve 218 has one wire-receiving lumen extendingtherethrough, the first sleeve 216 has more than one wire-receivinglumen, as discussed in more detail below.

As shown in FIGS. 5, 6, and 7A, the first elongate sleeve 216, which isconfigured to be removably and replaceably received in the first channel206, a proximal housing 210 configured to protrude from the proximal end200 p of the cannula 200. The proximal housing 210 has a generallycircular cross-section, although it can have other features such thatthe contour of the cross-section is only partially circular along aperimeter of the cross-section. Furthermore, in other implementations,the proximal housing 210 can have other configurations such that itscross-sectional shape is not circular.

As shown in FIGS. 5, 6, and 7A, the proximal housing 210 has a diameterthat is larger than a diameter of an elongate tubular body 212 of thefirst elongate sleeve 216 that extends distally from the housing 210.The diameter of the housing 210 is also larger than a diameter of theopening 206 o leading to the first channel 206 of the cannula 200, suchthat the housing 210 extends beyond the proximal end 200 p of thecannula 200 when the first sleeve 216 is inserted into the first channel206 in the cannula 200.

As shown in FIG. 7B, the proximal housing 210 of the first elongatesleeve 216 has three openings 220, 222, 224 formed therein. Each of thefirst, second, and third openings 220, 222, 224 is in communication witha respective one of first, second, and third wire-receiving lumens orchannels 230, 232, 234 that extend through the first elongate sleeve 216to the distal end 216 d thereof. The wire-receiving lumens 230, 232,234, each configured to receive a wire (e.g., a Kirschner or K-wire orother wires) therethrough, extend through the first elongate sleeve 216such that their respective longitudinal axes are disposed in the sameplane, as shown in FIG. 7C. In the illustrated example, as also shown inFIG. 7C, the second wire-receiving lumen 232 disposed between the firstwire-receiving lumen 230 and the third wire-receiving lumen 234 is acompletely enclosed lumen, whereas each of the first and third lumens230, 234 have a longitudinal portion of its walls open. It should beappreciated, however, that all of the wire-receiving lumens 230, 232,234 can be completely enclosed, or the configurations of the walls ofthe lumens 230, 232, 234 can vary in other ways.

The proximal housing 210 of the first elongate sleeve 216 can have otherfeatures. For example, in the example illustrated, the proximal housing210 has a coupling element that allows reversible coupling of the firstelongate sleeve 216 to the second elongate sleeve 218 such thatindependent rotation of the first and second sleeves 216, 218 is notpossible. Thus, as shown in FIGS. 7B and 7C, the proximal housing 210has an arcuate slot 213 configured to receive therein a portion of theproximal end 218 p of the second elongate sleeve 218 such thatindependent rotation of the first and second elongate sleeves 216, 218is not possible. It should be appreciated that the proximal housing 210can have other features not shown herein.

As shown in FIGS. 8A and 8B, the second elongate sleeve 218, the secondelongate sleeve 218, configured to be removably and replaceably receivedin the second channel 208, has a wire-receiving lumen 228 extendingtherethrough. In the example illustrated, the distal end 218 d of thesecond elongate sleeve 218 has a threaded portion 236 with a thread 237formed therearound, like in the example illustrated. The thread 237 canbe useful for other steps of a surgical procedure that are not relevantto this disclosure. The proximal end 218 p of the second elongate sleeve218 has an elongate portion 238 having several elongate arcuateprotrusions 239 extending along a longitudinal axis of the secondelongate sleeve 218, as shown in FIG. 8A. Although four or lessprotrusions 239 are shown, the number of protrusions is not critical andany number of protrusions can be present. The protrusions 239 canfacilitate grasping and manipulating sleeve 218 and, like the threadedproximal portion 236, can be useful for other aspects of a surgicalprocedure that are neither relevant nor described herein.

An elongate tubular mid-portion 240 of the second elongate sleeve 218extending between the proximal and distal ends 218 p, 218 d can have adiameter than is greater than a diameter of the distal end 218 p andsmaller than a diameter of the proximal end 218 p, as shown in FIG. 8A.A distal end of the elongate mid-portion 240 can be tapered distally, asshown in FIGS. 8A and 8B. It should be appreciated that the specificconfiguration of the second elongate sleeve 218 is shown herein by wayof example only, as the second elongate sleeve 218 can have othervarious configurations.

Referring back to FIGS. 7B and 7C, in the illustrated embodiments, thefirst elongate sleeve 216 is configured so as to define an offsetbetween one of its wire-receiving lumens 230, 232, 234 and thewire-receiving lumen 228 extending through the second elongate sleeve218. Specifically, each of the three openings 220, 222, 224 defines adifferent offset distance between the wire-receiving lumen incommunication with that opening and the wire-receiving lumen 228 of thesecond elongate sleeve 218. For example, the first, second, and thirdopenings 220, 222, 224 can define offset distances of about 11 mm, about9 mm, and about 7 mm, respectively. A person skilled in the art willappreciate, however, that the openings in the first elongate sleeve 216can define various offset distances (including those other than about 11mm, about 9 mm, and about 7 mm), as embodiments are not limited to anyspecific offsets. Furthermore, two or more than three openings leadingto corresponding lumens can be formed in the first elongate sleeve 216.

Regardless of the number of the openings in the first elongate sleeve216 and offsets defined by the openings, in use, each offset is used todefine a respective offset of openings to be formed in the bone. Forexample, an offset of an opening in a glenoid from a glenoid rim canthus be defined, as discussed in more detail below.

FIGS. 9 illustrates schematically a way in which the cannula 200 can bepositioned initially to prepare a bone, such as a glenoid 300 of ashoulder joint, for a surgical procedure involving placement of a graftbone to the glenoid 300. As shown, the cannula 200 can be positionedalong the glenoid anterior surface 302 (sometimes referred to herein asthe “end surface”) of the glenoid 300 defining the glenoid cavity suchthat it abuts a glenoid rim 304. As discussed above, the cannula 200 hasthe first and second parallel elongate channels 206, 208 extendingtherethrough that have the first and second sleeves 216, 218 receivedtherein, respectively. The proximal handle 204 coupled to the cannula200 is also shown partially in FIG. 9. As also shown in FIG. 9, a firstwire 303 is positioned in the lumen of the first sleeve 216 disposedsuch that the first wire 303 extends along a plane defined by the endsurface 302 of the glenoid 300. The method for preparing a bone,including subsequent steps not illustrated in FIG. 9, is described inmore detail below in connection with FIGS. 10A-10F.

FIGS. 10A-10F illustrate an exemplary implementation of a method forpreparing a bone, such as the glenoid 300 of a right shoulder joint 301shown partially in FIGS. 10A-10F, for a surgical procedure, inaccordance with the described techniques. The method involves using acannula 400 which is generally similar to cannula 200 (FIGS. 4A and 4B).The method is performed to define first and second openings in theglenoid 300 configured to receive therein bone screws for attaching abone graft to the glenoid 300.

A surgery for which the bone can be prepared in accordance with thedescribed techniques can be, for example, an arthroscopic bonetransplanting procedure for treatment of an anterior shoulderinstability, where a portion of a coracoid is transplanted to a glenoid.An example of such a surgery, as well as instruments that can be usedduring the surgery (which are not described herein), are described inU.S. Pat. No. 8,617,219 entitled “Arthroscopic Bone TransplantingProcedure, And Medical Instruments Useful Therein,” and filed Nov. 6,2009, which is hereby incorporated by reference in its entirety.

A patient (not shown) can be appropriately prepared for the surgery andbrought into a suitable position. A surgical site in the patient'sshoulder can also be prepared using suitable techniques. The cannula 400can then be introduced into the shoulder joint and it can be positionedalong the end surface 302 of the glenoid 300 defining the glenoidcavity. As shown in FIG. 10A, the cannula 400 is disposed parallel tothe glenoid surface such that a distal end 400 d of the cannula 400abuts the glenoid rim 304.

Like the cannula 200, the cannula 400 has first and second parallelelongate channels 406, 408 extending therethrough that have first andsecond sleeves 416, 418 received therein, respectively. The cannula 400extends distally from a proximal handle 404 coupled to the cannula 400at a proximal end 400 p of the cannula.

Similar to the proximal housing 210 of the first sleeve 216 received inthe cannula 200, a proximal housing 410 of the first sleeve 416 hasthree openings, each defining a different offset distance and leading toa respective wire-receiving lumen, and a coupling element configured tonon-movably couple the first sleeve 416 to the second sleeve 418.However, as shown in FIGS. 10A-10F, the proximal housing 410 has aconfiguration that differs in some aspects from that of the proximalhousing 210 of the first sleeve 216. For example, as indicated in FIG.10A, the proximal housing 410 has an elongate arcuate portion 411 inwhich three wire-receiving lumens 430, 432, 434 are formed, and thecoupling element 413 extending laterally from the arcuate portion 411 soas to be disposed at least partially around a portion at the proximalend of the second sleeve 418. In the example illustrated, the couplingelement 413 is formed integrally and/or monolithically with the arcuateportion 411 of the proximal housing 410. However, in otherimplementations, the coupling element can be a separate element that canbe coupled to one or both of the first and second sleeves in a suitablemanner so as to prevent rotation of the sleeves with respect to oneanother.

The coupling element 413 is in the form of a semi-arcuate bracket havingarms sized so as to receive the portion of the second sleeve 418 betweenthe arms. The bracket can be configured to reversibly snap over thesecond sleeve 418, or it can be configured to be otherwise attached tothe second sleeve 418. It should be appreciated that the couplingelement can have other configurations, as embodiments described hereinare not limited to any specific feature(s) used to reversibly couple thefirst and second sleeves so as to prevent their rotation with respect toone another. Also, the coupling element can alternatively be formed onthe second sleeve, or it can be a separate element configured to couplethe first and second sleeves.

In the example of FIGS. 10A-10F, the distal end 416 d of the firstsleeve 416 is in the form of a threaded portion. However, like thedistal end of the first sleeve 216 (FIGS. 5, 6, and 7A), the distal end416 d of the first sleeve 416 can lack the threaded portion. Otherconfigurations of the distal end, as well as other portions of the firstsleeve 416, can be implemented additionally or alternatively.

Openings 420, 422, 424 formed in the proximal housing 410 of the firstsleeve 416, each defining a different offset distance, lead to therespective wire-receiving lumens 430, 432, 434, as shown in FIG. 10A.The middle opening 422 leads to the wire-receiving lumen 432 in the formof an enclosed lumen. The openings 420, 424 are in the form of proximalends of the wire-receiving lumens 430, 434 each of which has a portionof its wall open along the longitudinal axis of the lumen.

The second sleeve 418 configured to be received in the second channel408 in the cannula 400 is configured similarly to the second sleeve 218received in the cannula 200. The second sleeve 418 has a wire-receivinglumen 428 extending therethrough, as shown in FIG. 10A.

Referring back to the method of preparing the glenoid 300 for a graftplacement procedure, as shown in FIG. 10A, the cannula 400 is positionedalong the end surface 302 of the glenoid 300 such that the first andsecond elongate channels 406, 408 are disposed in a first planeschematically shown as a plane P1. The cannula 400 abuts the glenoid rim304.

Once the cannula 400 is properly positioned, a first wire 306 ispositioned in the lumen of the first sleeve 416 disposed in the firstchannel 406 such that the first wire 306 extends along a plane definedby the end surface 302 of the glenoid 300, as shown in FIG. 10A. Adistal end 306 d of the first wire 306 can be blunt to avoid damage tocartilage. The first wire 306 can be a K-wire or other removableelongate element.

The first wire 306 is inserted into one of the plurality of openingsformed in the first sleeve 416 to thereby define a desired offsetdistance between the respective wire-receiving lumen in the first sleeve416 and the wire-receiving lumen extending through the second sleeve418. In the example of FIGS. 10A-10F, the first wire 306 is shown by wayof example only as being introduced into a middle opening 422. However,a person skilled in the art will appreciate that the first wire 306 canbe introduced into any of the openings formed at a proximal end 416 p ofthe first sleeve 416, depending on a desired offset distance of openingsto be formed in the glenoid from the edge 305 of the glenoid rim 304.

Regardless of which one of the openings in the first sleeve 416 receivesthe first wire 306, the first wire 306 in placed in front of the glenoidand advanced through tissue across the glenoid end surface 302, suchthat it is ultimately positioned against the farther edge 307 of theglenoid 300, as shown in FIG. 10A. When the cannula 400 is disposedadjacent to the glenoid during the bone preparation procedure, the firstsleeve 416 is positioned such that the first wire 306 extendingtherethrough does not penetrate the bone and extends along the surfaceof the glenoid. At the same time, as shown in FIG. 10A, a distal end 418d of the second sleeve 418 abuts the glenoid rim 304. The first wire 306is pressed against the glenoid surface, and it is “pinned” in place,without penetrating the bone, such that it serves to mark the locationof the surface 302 of the glenoid.

After the first wire 306 is received in the first sleeve 416, a secondwire 308 is positioned in the wire-receiving lumen 428 of the secondsleeve 418 that is received in the second channel 408, as shown in FIG.10B. Similar to the first wire 306, the second wire 308 can be a K-wireor other removable elongate element. The second wire 308 is advanceddistally through sleeve 418 such that a distal end 308 d of the secondwire 308 is inserted into a portion of the glenoid 300 spaced away fromthe end surface 302 to define the location of a first opening 330 in theglenoid 300. The second wire 308 can be inserted (e.g., drilled) intothe glenoid 300 to a relatively small distance, e.g., it can be insertedto a depth of about 5 mm into the glenoid bone. It should be appreciatedthat the second wire 308 can be inserted to other depths within theglenoid bone. Regardless of the specific depth to which the second wire308 is advanced through the glenoid, in this way, the location of thefirst opening 330 in the glenoid 300 is defined.

After locating the position of the first opening 330 in the glenoid 300is defined as indicated above, the first wire 306 is at least partiallyretracted from the first sleeve 416 in the first channel 406 so as tomove some distance away from the glenoid 300, such that the distal endthereof does not protrude from the distal end 400 d of the cannula 400.In the example illustrated, as shown in FIG. 10C, the first wire 306 iscompletely removed from the first channel 406.

After the first wire 306 is at least partially retracted from the firstchannel 406, and while the second wire 308 remains in place, the cannula400 is rotated about the second wire 308, as shown in FIG. 10D. Suchrotation can be effected by manipulating the handle 404 such that thehandle 404 is moved in the “up” direction (as shown in FIGS. 10C and10D) and the cannula 400 is aligned with the glenoid surface. Followingthis rotation of the first and second elongate channels 406, 408 aredisposed in a second plane P2 that is substantially perpendicular to thefirst plane P1, as shown in FIG. 10D. The cannula 400 is rotated aboutthe second wire 308 until the distal end of the first sleeve 416 abutsthe glenoid.

After the cannula 400 is rotated and while it remains in the positionshown in FIG. 10D, the first wire 306 is again inserted into the firstsleeve 416, positioned within the first channel 406, and advanceddistally until it is inserted through the glenoid 300 to thereby definethe location of a second opening 332 in the glenoid 300, as shown inFIG. 10E. The first wire 306 can be drilled completely through theglenoid. The second wire 308 can be inserted to an increased depth intothe glenoid such that its distal end 308 d is disposed more distally, asshown in FIG. 10F. In this way, both the first and second openings 330,332 in the glenoid 300 are formed.

FIG. 11 illustrates the first and second openings 330, 332 formed at aspecified 336 offset distance from the edge 305 of the glenoid rim 304.FIG. 12 additionally shows the glenoid 300 with the openings 330, 332formed therein.

After the first and second openings are formed, they can be widenedusing a suitable instrument (e.g., a drill or other bone cuttinginstrument) such that they are appropriately dimensioned to receiverespective first and second bone screws therein. A bone graft can beacquired by known surgical techniques, for example, similar to thetechnique shown in connection with FIGS. 1A and 1B. As discussed above,a coracoid can be osteotomized (e.g., using an osteotome or othercutting tool) using an approach as known in the art to form a coracoidbone graft having a tendon attached thereto.

The coracoid bone graft can be placed over the first and second wiresextending through the cannula, and the bone graft can be attached to theglenoid 300 using first and second screws.

It should be appreciated that, although not described herein, variousother instruments can be used during the surgical procedure, examples ofwhich are described in U.S. Pat. No. 8,617,219 entitled “ArthroscopicBone Transplanting Procedure, And Medical Instruments Useful Therein,”and filed Nov. 6, 2009, which is hereby incorporated by reference in itsentirety.

It should also be appreciated that the surgical guide device describedherein can have any number of variations. For example, in someembodiments, the cannula, such as cannula 200 (FIGS. 4A and 4B) orcannula 400 (FIGS. 10A-10E), or a similar cannula, can be formed suchthat the first elongate channel and the first elongate sleeve are notseparate elements but are rather formed as one component. The secondelongate channel and second first elongate sleeve can similarly beformed as one component. In such cases, the first and second elongatesleeves can be configured to be non-removably received in the first andsecond channels, respectively. As another variation, the first andsecond elongate sleeves can be integrally and/or monolithically formedwith the first and second channels, respectively.

The techniques described herein can be used to position a bone graftadjacent to the bone, such as the glenoid or other bone structure, tocompensate for the bone deficit in the bone such that the surface of thebone graft is flush with the surface of the bone. Thus, certainshortcomings associated with the conventional Latarjet surgery can bealleviated. Specifically, because the openings in the bone are formed inthe straightforward manner, the reliance on a surgeon's experience isreduced. As a result, a possibility of an incorrect positioning of thebone graft with respect to the bone, and thus of the associated damageto the bone, is greatly decreased or even completely eliminated. Thus,when the bone is prepared as described herein, this contributes to thesuccessful outcome of the surgery.

It should be appreciated that the described techniques can be used forpreparing a bone to receive a bone graft as part of a number ofdifferent procedures. For example, a bone can be prepared for a Bristowprocedure or its variants, a Trillat procedure for recurrent anteriorinstability of the shoulder, or any other procedure, including anteriorand posterior bone bloc procedures. Also, although the illustratedembodiments provide techniques for preparing a glenoid for a shoulderjoint reconstruction surgery, the techniques can be adapted forpreparation of other bones as well.

A bone graft can be any suitable graft. For example, it can be, as inthe embodiments described above, an autograft, which is a patient's ownbone with the tendon coupled thereto that would replace the damagedportion of another bone. The bone graft can also be obtained from adonor (“allograft”). The graft can be an iliac crest bone graft, or anyother graft.

Furthermore, although the illustrated embodiments provide techniques forpreparing a bone for receiving a bone graft in a surgical procedure, thetechniques can be used for other surgical procedures as well. Forexample, the techniques can be used for placing an implant at a certaindesired distance from an edge of a bone. In such cases, the implants canbe used to reattach soft tissues to the bone. As another example, thedescribed techniques can be used for a trauma reconstruction surgery toplace an implant, intended to fix a fracture or other trauma, at acertain distance from an edge of a bone. It should be furtherappreciated that the described techniques can be used to prepare a bonefor any other procedure.

The devices disclosed herein can be designed to be disposed of after asingle use, or they can be designed to be used multiple times. In eithercase, however, the device can be reconditioned for reuse after at leastone use. Reconditioning can include any combination of the steps ofdisassembly of the device, followed by cleaning or replacement ofparticular pieces, and subsequent reassembly. In particular, the devicecan be disassembled, and any number of the particular pieces or parts ofthe device can be selectively replaced or removed in any combination.Upon cleaning and/or replacement of particular parts, the device can bereassembled for subsequent use either at a reconditioning facility, orby a surgical team immediately prior to a surgical procedure. Thoseskilled in the art will appreciate that reconditioning of a device canutilize a variety of techniques for disassembly, cleaning/replacement,and reassembly. Use of such techniques, and the resulting reconditioneddevice, are all within the scope of the present application.

Preferably, the devices and components described herein will beprocessed before use. First, a new or used instrument is obtained and ifnecessary cleaned. The instrument can then be sterilized. In onesterilization technique, the instrument is placed in a closed and sealedcontainer, such as a plastic or TYVEK bag. The container and instrumentare then placed in a field of radiation that can penetrate thecontainer, such as gamma radiation, x-rays, or high energy electrons.The radiation kills bacteria on the instrument and in the container. Thesterilized instrument can then be stored in the sterile container. Thesealed container keeps the instrument sterile until it is opened in themedical facility.

It is preferred that device is sterilized. This can be done by anynumber of ways known to those skilled in the art including beta or gammaradiation, ethylene oxide, steam, and a liquid bath (e.g., cold soak).An exemplary embodiment of sterilizing a device including internalcircuitry is described in more detail in U.S. Pat. Pub. No. 2009/0202387filed Feb. 8, 2008 and entitled “System And Method Of Sterilizing AnImplantable Medical Device.” It is preferred that device, if implanted,is hermetically sealed. This can be done by any number of ways known tothose skilled in the art.

One skilled in the art will appreciate further features and advantagesof the described techniques based on the above-described embodiments.Accordingly, the present disclosure is not to be limited by what hasbeen particularly shown and described, except as indicated by theappended claims. All publications and references cited herein areexpressly incorporated herein by reference in their entirety.

What is claimed is:
 1. A surgical guide device, comprising: a cannulacomprising first and second parallel elongate channels positionedadjacent to one another; a first elongate sleeve configured to beremovably and replaceably received in the first channel, the firstsleeve having a proximal housing configured to protrude from a proximalend of the cannula, the proximal housing of the first sleeve having aplurality of openings formed therein, each opening being incommunication with a respective wire-receiving lumen that extendsthrough the first elongate sleeve to a distal end thereof; and a secondelongate sleeve configured to be removably and replaceably received inthe second channel, the second sleeve having a proximal end configuredto protrude from the proximal end of the cannula when the second sleeveis positioned therein, the second sleeve having a wire-receiving lumenextending therethrough.
 2. The surgical guide device of claim 1, whereineach of the openings defines a different offset distance between thewire-receiving lumen in communication with the opening and thewire-receiving lumen extending through the second elongate sleeve. 3.The surgical guide device of claim 1, wherein the cannula extends from aproximal handle, the handle defining a first longitudinal axis that isat a non-zero angle to a second longitudinal axis defined by the firstelongate channel and a third longitudinal axis defined by the secondelongate channel.
 4. The surgical guide device of claim 1, wherein thefirst and second parallel elongate channels are discrete and separatechannels.
 5. The surgical guide device of claim 1, wherein the first andsecond elongate sleeves are removably and replaceably disposed in thefirst and second elongate channels via a clearance fit.
 6. The surgicalguide device of claim 1, wherein with the first elongate sleeve receivedin the first channel and with the second elongate sleeve received in thesecond channel, the second elongate sleeve is configured to extend moreproximally beyond a proximal end of the cannula than the first elongatesleeve.
 7. The surgical guide device of claim 1, wherein the housing ofthe first elongate sleeve is an elongate tubular housing having adiameter that is larger than a diameter of an opening leading to thefirst channel of the cannula.
 8. The surgical guide device of claim 1,wherein a distal end of the second elongate sleeve has a threadedportion.
 9. The surgical guide device of claim 1, wherein the distal endof the first elongate sleeve is configured to extend beyond a distal endof the cannula when the first elongate sleeve is positioned therein. 10.The surgical guide device of claim 1, wherein a distal end of the secondelongate sleeve is configured to extend beyond a distal end of thecannula when the second elongate sleeve is positioned therein.
 11. Thesurgical guide device of claim 1, further comprising a coupling elementconfigured to couple the first elongate sleeve to the second elongatesleeve so as to prevent rotation of the first and second elongatesleeves with respect to one another.
 12. A surgical guide device,comprising: an elongate body with first and second elongate channelsextending therethrough; a handle coupled to the elongate body, thehandle defining a first longitudinal axis that is at a non-zero angle toa second longitudinal axis defined by elongate body; a first elongatesleeve configured to be removably and replaceably received in the firstchannel, wherein a plurality of lumens extend longitudinally along thefirst elongate sleeve, and with the first elongate sleeve removably andreplaceably received in the first channel, each of the lumens isconfigured to have an elongate fixation element advanced therethroughsuch that a distal end of the elongate fixation element exits and ispositioned distal to a distal opening of the first elongate channel; anda second elongate sleeve configured to be removably and replaceablyreceived in the second channel, wherein only one lumen extendslongitudinally along the second elongate sleeve, and with the secondelongate sleeve removably and replaceably received in the secondchannel, the one lumen is configured to have a second elongate fixationelement advanced therethrough such that a distal end of the secondelongate fixation element exits and is positioned distal to a distalopening of the second elongate channel.
 13. The surgical guide device ofclaim 12, wherein the first and second elongate channels are parallel toone another and are discrete and separate from one another.
 14. Thesurgical guide device of claim 12, wherein at least one of the pluralityof lumens of the first elongate sleeve is a completely enclosed lumen,and at least one other of the plurality of lumens of the first elongatesleeve has a longitudinal portion of its wall open.
 15. The surgicalguide device of claim 12, further comprising the elongate fixationelement and the second elongate fixation element.
 16. The surgical guidedevice of claim 15, wherein each of the elongate fixation element andthe second elongate fixation element comprises a wire.
 17. The surgicalguide device of claim 15, wherein the elongate body is configured to berotated about the second elongate fixation element with the secondelongate fixation element positioned within the one lumen with thedistal end thereof having exited the distal opening of the secondelongate channel.
 18. The surgical guide device of claim 15, wherein theone lumen of the second elongate sleeve is configured to have the secondelongate fixation element advanced therethrough such that the distal endof the second elongate fixation element exits and is positioned distalto the distal opening of the second elongate channel with the distal endof the elongate fixation element positioned distal to the distal openingof the first elongate channel.
 19. A surgical method, comprising:positioning a distal end of a cannula relative to a bone; advancing afirst elongate sleeve through a first elongate channel extending throughthe cannula and then advancing a first elongate fixation element alongone of a plurality of lumens extending along the first elongate sleevesuch that a distal end of the first elongate fixation element exits thefirst elongate channel and contacts the bone; advancing a secondelongate sleeve through a second elongate channel extending through thecannula and then advancing a second elongate fixation element along alumen extending along the second elongate sleeve such that a distal endof the second elongate fixation element exits the second elongatechannel and enters into the bone; and with the second elongate fixationelement in the bone, rotating the cannula relative to the secondelongate fixation element and the bone.
 20. The method of claim 19,wherein the first elongate fixation element is advanced along the one ofthe plurality of lumens before the cannula is rotated, and the methodfurther comprises: retracting the first elongate fixation element in theone of the plurality of lumens before rotating the cannula; and afterrotating the cannula, again advancing the first elongate fixationelement along the one of the plurality of lumens such that the distalend of the first elongate fixation element exits the first elongatechannel and enters the bone.